GORD Flashcards
GORD is a very common condition, which is characterised by symptoms of … and …
GORD is a very common condition, which is characterised by symptoms of heartburn and regurgitation.
Gastro-oesophageal reflux disease (GORD), is an extremely … condition. It is defined as reflux of stomach contents into the oesophagus, which is associated with troublesome symptoms and/or complications.
Gastro-oesophageal reflux disease (GORD), is an extremely common condition. It is defined as reflux of stomach contents into the oesophagus, which is associated with troublesome symptoms and/or complications.
What is the estimated prevalence of GORD in Western Europe and North America?
In Western European and North American populations, the estimated prevalence is as high as 10-20%.
High … and … are linked to development of GORD.
High BMI and smoking are linked to development of GORD.
In some individuals, reflux of stomach contents causes troublesome heartburn symptoms and can cause damage to the oesophageal lining. Over time, this may lead to complications including …, strictures and … oesophagus. Factors implicated in GORD include:
Frequency of … episodes
… of the stomach content
… of acid from the oesophagus.
In some individuals, reflux of stomach contents causes troublesome heartburn symptoms and can cause damage to the oesophageal lining. Over time, this may lead to complications including erosions, strictures and Barrett’s oesophagus. Factors implicated in GORD include:
Common risk factors for GORD
High BMI
Smoking
Genetic association
Pregnancy
Hiatus hernia: part of the upper stomach pushes up through the diaphragm
NSAIDs, caffeine & alcohol: conflicting reports
What is the cardinal symptom of GORD?
The cardinal symptom of GORD is heartburn, which describes a burning sensation in the centre of the chest.
… classically occurs after meals and is made worse by lying down or bending forward.
Heartburn classically occurs after meals and is made worse by lying down or bending forward.
Other common features of GORD:
Regurgitation Dyspepsia Chest pain Dysphagia (difficulty swallowing) Odynophagia (painful swallowing) Cough Hoarse voice Nausea and/or vomiting
What is odynophagia?
Painful swallowing
Collectively, the clinical manifestations of GORD can be divided into …. and …-… syndromes.
Collectively, the clinical manifestations of GORD can be divided into oesophageal and extra-oesophageal syndromes.
Oesophageal clinical manifestations of GORD: (6)
Typical reflux syndrome
Reflux chest-pain syndrome
Reflux oesophagitis (inflammation and damage of oesophageal mucosa)
Reflux stricture (narrowing of oesophagus)
Barrett’s oesophagus (premalignant condition in the oesophagus)
Oesophageal adenocarcinoma
Extra-oesophageal clinical manifestations of GORD:
Reflux cough syndrome Reflux laryngitis syndrome Reflux asthma syndrome Reflux dental erosion syndrome Proposed associations: idiopathic pulmonary fibrosis, sinusitis, etc
GORD is a … diagnosis based on characteristic symptoms.
GORD is a clinical diagnosis based on characteristic symptoms.
GORD is extremely common and can be diagnosed based on characteristic symptoms. There are several red flags, which should make you concerned about an alternative diagnosis and need for upper gastrointestinal (GI) endoscopy (i.e. gastroscopy) - what are these red flags? (5)
Weight loss Anaemia Dysphagia New onset dyspepsia (>55 years) Symptoms refractory to treatment
It may be difficult to distinguish reflux-associated chest pain from ….
It may be difficult to distinguish reflux-associated chest pain from cardiac chest pain.
Differential diagnosis of heartburn: (7)
Functional heartburn Achalasia (failed relaxation of LOS) Eosinophilic oesophagitis Pericarditis Ischaemic heart disease Peptic ulcer disease Malignancy
The two key investigations in GORD are …
The two key investigations in GORD are gastroscopy and pH monitoring.
…. monitoring - may be utilised where the diagnosis is uncertain or surgery is being considered in GORD - combined with gastroscopy
PH monitoring - may be utilised where the diagnosis is uncertain or surgery is being considered in GORD - combined with gastroscopy
There are two techniques for assessing pH: what are they?
24-hour pH monitoring: small tube inserted through the nose and positioned in lower oesophagus. Can be combined with high resolution manometry (assesses motor abnormalities of the oesophagus).
Wireless pH capsules testing: insertion of pH capsule at gastro-oesophageal junction during gastroscopy. Carry recording device to capture episodes. Will naturally fall off wall of oesophagus and pass through GI tract.
…-… … monitoring: small tube inserted through the nose and positioned in lower oesophagus. Can be combined with high resolution manometry (assesses motor abnormalities of the oesophagus).
24-hour pH monitoring: small tube inserted through the nose and positioned in lower oesophagus. Can be combined with high resolution manometry (assesses motor abnormalities of the oesophagus).
…. pH …. testing: insertion of pH capsule at gastro-oesophageal junction during gastroscopy. Carry recording device to capture episodes. Will naturally fall off wall of oesophagus and pass through GI tract.
Wireless pH capsules testing: insertion of pH capsule at gastro-oesophageal junction during gastroscopy. Carry recording device to capture episodes. Will naturally fall off wall of oesophagus and pass through GI tract.
When is gastroscopy indicated in GORD?
Gastroscopy is usually reserved for patients with red flags symptoms, suspected complications, symptoms refratory to treatment or those being considered for surgery.
Gastroscopy is able to diagnose the presence of oesophagitis, Barrett’s oesophagus or an alternative diagnosis (i.e. oesophageal/gastric malignancy). Up to …% of patients with GORD will have a normal gastroscopy.
Gastroscopy is able to diagnose the presence of oesophagitis, Barrett’s oesophagus or an alternative diagnosis (i.e. oesophageal/gastric malignancy). Up to 50% of patients with GORD will have a normal gastroscopy.
Los Angeles classification
The severity of oesophagitis can be graded into … - … using the Los Angeles classification:
Grade A: ≥1 mucosal break, each ≤ 5mm
Grade B: ≥1 mucosal break > 5mm. Not continuous between top of mucosal folds.
Grade C: ≥1 mucosal break, continuous between top of mucosal folds, not circumferential
Grade D: mucosal breaks involving more than three quarters of luminal circumference.
Reflux can be divided into four different phenotypes based on endoscopy findings and pH monitoring - what are they?
Four reflux phenotypes:
Erosive oesophagitis: erosions seen at gastroscopy
Non-erosive oesophageal reflux: normal gastroscopy, but pathological acid exposure on pH testing
Acid hypersensitive oesophagus: normal gastroscopy, non-pathological acid exposure on pH testing but temporal association of reflux events with symptoms
Functional heartburn: normal gastroscopy, non-pathological acid exposure on pH testing and no temporal association of reflux events with symptoms.
… …: erosions seen at gastroscopy
Erosive oesophagitis: erosions seen at gastroscopy
Non-… oesophageal reflux: normal gastroscopy, but pathological acid exposure on … testing
Non-erosive oesophageal reflux: normal gastroscopy, but pathological acid exposure on pH testing
Acid … oesophagus: … gastroscopy, non-pathological acid exposure on pH testing but temporal association of reflux events with symptoms
Acid hypersensitive oesophagus: normal gastroscopy, non-pathological acid exposure on pH testing but temporal association of reflux events with symptoms
…. heartburn: normal gastroscopy, non-pathological acid exposure on pH testing and no temporal association of reflux events with symptoms.
Functional heartburn: normal gastroscopy, non-pathological acid exposure on pH testing and no temporal association of reflux events with symptoms.
What is the main treatment in GORD?
The use of proton pump inhibitors (PPIs) is the cornerstone of treatment in GORD.
Conservative GORD management -
There is variable evidence for lifestyle modifications in GORD. These include weight loss, smoking cessation and dietary modifications. Patients should be advised to avoid eating within two hours of sleep and elevation of the head of the bed may be helpful.
Medical GORD management:
PPIs form the cornerstone of GORD treatment. PPIs prevent acid production within the stomach through inhibition of H+/K+ ATPases in parietal cells.
Patients with typical reflux symptoms can be offered a two-week PPI trial. Response is variable (40-90%). Alternative options include ranitidine, which is a histamine receptor antagonist, and over the counter antacids that can be used in combination with medications to neutralise stomach acid.
Patients with evidence of erosions should be offered PPIs to promote healing as they have the best efficacy.
Patients with evidence of erosions should be offered … to promote healing as they have the best efficacy.
Patients with evidence of erosions should be offered PPIs to promote healing as they have the best efficacy.
Patients with typical reflux symptoms can be offered a …-…. PPI trial. Response is variable (40-90%). Alternative options include ranitidine, which is a … receptor antagonist, and over the counter antacids that can be used in combination with medications to neutralise stomach acid.
Patients with typical reflux symptoms can be offered a two-week PPI trial. Response is variable (40-90%). Alternative options include ranitidine, which is a histamine receptor antagonist, and over the counter antacids that can be used in combination with medications to neutralise stomach acid.
How do PPIs prevent acid production within the stomach?
PPIs prevent acid production within the stomach through inhibition of H+/K+ ATPases in parietal cells.
What is the main surgical option for GORD?
The role of surgery has increased over the last decade. The main option being a Nissen fundoplication. This procedure involves wrapping the fundus of the stomach around the lower oesophagus. A good response to PPI therapy is associated with a good response to surgery, so patient selection is paramount.
What happens in a Nissen fundoplication?
This procedure involves wrapping the fundus of the stomach around the lower oesophagus. A good response to PPI therapy is associated with a good response to surgery, so patient selection is paramount.
When is surgery used in GORD?
Surgery is generally reserved for patients with clear evidence of reflux or associated complications who do not want to take medications or develop side-effects preventing long-term use.
The major complications associated with gastro-oesophageal reflux include (3)
The major complications associated with gastro-oesophageal reflux include erosions, stricture and Barrett’s oesophagus.
Reflux can lead to recurrent inflammation and damage of the … …. This predisposes to erosions, … formation due to chronic scarring and … transformation.
Reflux can lead to recurrent inflammation and damage of the oesophageal mucosa. This predisposes to erosions, stricture formation due to chronic scarring and malignant transformation.
What is Barrett’s oesophagus?
Barrett’s oesophagus: a premalignant condition due to columnar metaplasia (transformation of one cell type to another) of the normal squamous oesophageal mucosa. Predisposes to the development of oesophageal adenocarcinoma.
What are strictures?
Stricture: scarring and narrowing of the oesophagus due to repeated damage. Can cause dysphagia. May require dilatation or stenting.
What is erosive oesophagitis?
Erosive oesophagitis: Inflammation of the oesophagus, which can lead to ulcers, bleeding and peptic stricture formation.
